Abstract

This study aims to examine selected

Social Support and Burden
among Caregivers of
factors of dementia patients and
their caregivers that were associated
with the burden of family
caregivers. This cross sectional
study involves face-to-face interview
Patients with Dementia in
with family caregivers of patients
with dementia. Participants were
recruited through convenient
Malaysia
sampling from geriatric and
psychiatry outpatient clinics from Wan-Yuen Choo
, MMedSc, BSc
1
three government hospitals, one Wah-Yun Low
, PhD, Cpsychol
1
university hospital, one rural health Razali Karina
, MSc, BA
2
centre and Alzheimer Disease
, MB, MRCP
PJH Poi
3
caregivers’ support groups. 70 Esther Ebenezer
, MBBSM, MPM
4
caregivers took part in the study. , MD, MSc
MJ Prince
5
Measures included patient and
caregiver demographic variables Health Research Development Unit, University Malaya Medical Centre, Kuala Lumpur,
1
and caregiver burden using the
Zarit Burden Interview (ZBI). Malaysia.
Caregiver burden was found to be Department of Social and Preventive Medicine, University Malaya Medical Centre,
2
Kuala Lumpur, Malaysia.
significantly associated with both Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
3
ethnicity and informal support. Department of Psychological Medicine, University Malaya Medical Centre, Kuala
4
Chinese caregivers were found to Lumpur, Malaysia
have a higher level of burden Institute of Psychiatry, King’s College, London
5
compared to Indians and Malays.
Informal support, in particular
assistance from family members, -<9
was significantly associated with a
lower burden perceived by the emotional support and social
’

Introduction . . ’°&dquo; .

caregivers. However, the study isolation’.

shows that formal support such as
assistance from maids and private
nurses did not alleviate the burden
of caregivers. Results highlighted
the importance of improving the
coping skills in burdened caregivers
particularly among family members
with dementia relatives.
Interventions should be designed for
specific needs of caregivers of
different ethnicities. Asia Pac J
Public Health 2003; 15(1): 23-29.
Keywords Mental health, burden,
: immune system, risk of cardiovascular
social support, dementia.
Address for correspondence:
Wan-Yuen Choo
Health Research Development Unit,
University Malaya Medical Centre
50603 Kuala Lumpur
Malaysia.
Tel: 603-79675748
Fax: 603-79675769
Email: ccwy@um.edu.my
Dementia patients are usually no
longer able to take complete control
of their lives and many of them need
major assistance to perform activities
associated with daily living. Caring
for dementia patients poses significant
challenges to caregivers. The
caregiver’s role is often linked with
psychological and physical morbidity,
including higher than usual
psychotropic drug use, alcohol,
cigarettes, and mood-altering drugs,
poor self-rated health, impaired
disease and depression’. Caregivers
themselves report facing more stress,
psychological problems, physical
health problems, social isolation and
family conflicts, than do persons who
are not caregivers. Caregivers who are
highly stressed are more likely to
cause depression, abuse or neglect,
and institutionalisation of care
recipients. This may be a direct
consequence of caregivers’ anger,
inability to cope, care recipient’s
behavioural disturbance, lack of
The burden of care giving, as
defined by Zarit et al. 3, can be
understood as the extent to which
caregivers perceived their emotional
or physical health, social life and
financial status to be adversely
affected as a result of caring for their
relatives. Caregiver burden is mainly
affected by two types of factors;
patient variables and caregiver
variables with the latter being the
stronger predictor of caregiver
outcomes. Patient variables have less
impact on caregiver burden except for
behavioural problems2. Other patient
variables such as cognitive
impairment, functional impairment,
duration of illness and severity of
impairment do not show consistent
association with caregivers’ burden4.
Caregiver variables, on the other
hand, have a much greater impact on
burden. Caregiver variables include
demographic variables such as
caregiver’s age, ethnicity, level of
education, household income, and
other variables such as health status,

23
social support and relationship
between the patient and caregiver.
Caregiver’s age usually is an indirect
predictor as older caregivers report
poorer health which would determine
burden’. Female caregivers tend to
report greater stress in many studies5.
With regard to the association between
ethnicity and burden, the literature is
intriguing. While previous studies did
not focus much on the ethnicity
differences in care-giving, recent
studies shows that ethnicity and
culture influence the care-giving
process that would impact upon a
perceived burden by caregivers’.
Caregiver-patient relationship is
an important contributor to overall
caregiver burden. Current research
found that spouse caregivers tend to
report more burden than adult children
while daughters-in-law are more
vulnerable to stress than adult or
spousal caregivers’. The availability
of social support and network is
important it provides both
as
instrumental and emotional support to
caregivers. Caregivers with less social
network and low satisfaction with the
support they received were reported
to have a significantly higher burden
than caregivers with stronger social
ties’. The extent of caregivers’
available social support and network
served as the most important stress
mediator2. According to Zarit et a1.3,
the extent of burden reported by
primary caregivers of persons with
dementia was not related to the
behaviour problems caused by the
illness but was associated with the
social support available, specifically
the number of visitors to the
household. The concept of social
support as a buffer against stress in
crisis situations is not new. &dquo;Positive&dquo;
social support has been demonstrated
to enhance adaptation to illness,
whereas &dquo;negative&dquo; social support
may result in the exacerbation of
patient or caregiver outcomes such as
depression and psychosocial distress.
Positive social support comprises
either instrumental or emotional, or
both. The relative importance of one
type of support over the other may
vary over the course of illness. For
example, instrumental support may be
particularly helpful during the acute
phases of some chronic illnesses,
24
when symptoms may limit
individuals’ abilities to perform daily
tasks on their own while for some
other people, ongoing disability may
require ongoing compensatory
assistance. There may be times,
however, when emotional support may
be equally important, or more
important, than instrumental help. In
some situations, particularly when
illness and disability isolate the
individual from the mainstream, the
need for emotional support may be
constant’. Caregivers who have a
greater emotional and social support
usually report low levels of depression
and high levels of life satisfaction’. In
addition, caregivers who are actively
engaged in social and recreational
activities, such as church attendance
or visiting with family members and
friends, also adapt to care-giving with
less depression than those who are
more socially isolated’. A sense of
control has been proposed as one
psychological mechanism underlying
the relationship between perceived
support and psychological well-being
during stressful experiences.
Knowing that others are available
when needed to help manage stressors
or difficulties may sustain or bolster
an individual’s sense of control over
particular stressful or difficult
situations that occur. Subsequently, a
sense of control concerning one’s
ability to handle particular situations
may protect or promote psychological
or emotional well-being. Control was
conceptualised as the belief about
one’s capability or competence to
influence or manage the specific
situation at hand. Atienza et al. 9 in their
study show that control beliefs
decreased after a stressor. Believing
that support will be available when
needed (for example, perceived social
support) can act as a buffer of the
negative effects of stress on
psychological well-being.
As dementia patients rely heavily
on family members for care-giving,
adequate consideration of the needs of
dementia caregivers and their role in
patient care is of great importance in
any attempt to provide comprehensive
healthcare services for patients with
dementia. Knowledge surrounding
issues of dementia care-giving,
including an understanding of factors
that predict care-giving outcome,
family and caregiver assessment and
resources or interventions for
caregiver, will assist health personnel
to provide a higher level of care for
the patients with dementia.
To date, little research and effort
have been carried out in Malaysia to
address the health care needs of
dementia patients and their caregivers.
The current study aimed to fill the gaps
of limited data available in Malaysia
on dementia caregivers by
investigating the impact of care on
caregivers who provide care for a
family member with dementia. This
study examined selected socio-
demographic factors and social
support towards the burden of care-
giving experienced by caregivers of
dementia patients.
Design and Methods
A cross-sectional convenience sample
of 70 persons caring for family
members diagnosed with dementia
was identified. The fieldwork was
conducted over a period of four
months. Persons caring for a family
member diagnosed with dementia
were recruited from several sources;
mainly the Alzheimer’s Disease
Foundation Malaysia, two district
hospitals, one university hospital, and
rural health centres from various states
in Malaysia.
Operationally, a caregiver, in this
study, is defined as a family member
who provides care for an elderly
relative with dementia who needs
assistance in performing activities
associated with daily living either
physically, financially, socially or
psychologically. The caregiver
selection criteria included the
following: the care recipients had been
diagnosed with some type of
dementia; the care recipients needed
help which included helping with
personal needs, household chores,
financial assistance, providing
transportation when necessary; the
caregiver was a family member of the
dementia patient who knows the
patient well and has an idea of how
the patient typically behaves; and able
to understand one of these languages
(Bahasa Malaysia, English or
Mandarin). Caregiver exclusion
criteria include caringfor more than
one chronically ill person in the family.
All subjects were contacted by
telephone to invite them to participate
in the study with the exception of
participants from the university
medical centre. An appointment was
scheduled for an in-the-home
interview with the caregiver who
volunteered to participate. A face-to-
face interview was conducted which
took approximately 45-60 minutes.
Participants from the university
hospital were caregivers of patients
seen in the Geriatric and Psychiatric
Clinic and they were interviewed at
the clinic. Written informed consent
was obtained prior to interview. The
socio-demographic data of the patients
and caregivers are described in Table
I and Table 2.
Research instruments
version of ZBI translated by Chiu and (SD =
8.67 years). Sixty percent of
her colleagues 12 was adopted to be the demented patients fell into the old-
used in this study. Data were analysed old category (more than 74 years)
using the Statistical Package for Social while 36% were from the young-old
Sciences (SPSS) Windows Version 10. group (60 - 74 years). The remaining
4% had early onset dementia.
Results
Table 2. General characteristics of
Dementia patients’ profile
dementia caregivers
The response rate of this study was
88%. The general characteristics of
the dementia patients and their
caregivers are presented in Table 1 and
Table 2, respectively.
Socio-demographic data
identified that the age of care-
recipients ranged from 55 years to 94
years with a mean age of 75.6 years
Table 1. General characteristics of
dementia patients

The caregivers were assessed using a

closed-ended questionnaire focusing
on socio-demographic characteristics
of the dementia patients and their
caregivers, and formal and informal
support. Formal support referred to
paid service by a nurse or a maid who
was privately employed to provide
assistance and supervision of the
activities of daily living of the patient
or involved in doing other household
chores for the patient or the caregiver.
Informal support was defined as
family members, friends and
neighbours who provided emotional
and physical support to caregivers.
The Zarit Burden Interview
consisting of 22 items was used to
measure the burden. The interview
was based on a Likert scale ranging
from 0 to 4 on how often they have
felt that various aspects of care-giving
have affected their life (0= never, 1=
rarely, 2= sometimes, 3= quite
frequently, and 4= nearly always). The
ZBI was scored by summing the
responses of the individual items.
Higher scores indicate greater burden.
The range of possible scores was
between 0 and 88. Previous studies
have shown that a high reliability and
validity of the ZBI’o.
The questionnaires originally in
English were translated into the
Bahasa Malaysia via the back
translation technique&dquo;. The Chinese ’Missing values were excluded, US$1 =
RM3.84

25
Comparing males and females, it is
obvious that a far greater percentage
of dementia patients found in this
study were females. The majority
(55%) of the care-recipients received
primary education or lower (no
education, 29% and primary
education, 26%). In this study, most
dementia patients were Chinese
(51 %), followed by the Malays (26%)
and Indians (21 %). Fifty-two percent
of them had a living spouse, 44% were
widows or widowers and the
remaining 3% were singles.
Duration of dementia condition
varied from six months to 12 years.
Median duration of illness was four
years (SD=2.92 years). Only 20% of
the patients were reported as having a
family history of dementia.
Socio-demographic characteristics
of the caregivers
The mean age of caregivers was 52.3
years (SD=12.8 years). More than half
of them were aged 56 years and above.
This indicates that care for the
demented elderly are provided by
either spouses or adult children who
would probably either be in their fifties
or sixties or more. The situation may
cause strain to the caregivers as they
themselves are likely to have health
problems of their own and yet have to
care for their relatives who suffer from
dementia.
In comparison to their elderly
demented relatives, many of the
caregivers received secondary or
higher education. One would expect
this in view of the fact that access to
education is almost universal after the
post-colonial period. Two-thirds of
the caregivers were from medium and
high household income groups with
median household income of
RM2,000 (SD= RM4,387). Also,
more than half ofcaregivers in this
study were housewives, unemployed
or retirees. Horowitz’3 suggested that
such situation is common as the care-
giving responsibilities are often
delegated to family members with the
least economic value. Although we
did not explore the effect of care-
giving on employment, Ory and
coworkers’4 found that there is a their siblings and provide financial
significantly higher percentage of
dementia caregivers reportedly
26
needing to take less demanding jobs,
early retirement, turning down a
promotion, losing job benefits and
having to give up entirely than non-
demented caregivers.
As noted earlier, due to societal
roles and expectations, female
caregivers are the largest contributor
in the care-giving activities and
responsibilities. This study shows that
daughters are still the major group of
caregivers. Much to our expectation,
the majority of the caregivers in this
study live with their dementia relative.
The Burden and socio-
’
demographic variables
The ZBI scores among the caregivers
ranged from 6 to 68. With a possible
range of scores of 0-88, the mean score
was 35.4 (SD=15.08), indicating that
caregivers experienced a moderate
amount of burden. Only 5.7%of the
caregivers were severely burdened.
Table 3 shows the association
between various socio-demographic
data, social support and burden. The
result shows a statistical significance
(F=3.246, ~/=69, p<_0.05) between
ethnic differences and burden. Among
the three major ethnic groups, the
Malays (X=27.94) seem to have the
lowest score as compared to the other
two ethnic groups; the Chinese
(X 38.61) and the Indians (X=3 6.3 7).
The statistical analysis also
revealed that the difference of burden
scores between age, gender,
caregivers’ relationship with patients,
level of education and household
income were statistically not
significant. One could perhaps
attribute this to the small sample size.
Burden and social support
An association between burden and
social support exists (X2=3.61 1, dp 1,
p<_0.05) where those with social
support perceived a lower burden. The
analysis was further subdivided to
formal and informal social support.
The data shows that two-thirds
of the total caregivers were caring for
the patients full time. The rest share
the care-giving responsibility with
support as well as other
responsibilities when his/her
assistance is needed. Caregivers who
assume the caring job full time have
higher scores than those caregivers
who share the responsibilities with
siblings; and those simply providing
financial support and other assistance.
Significant heterogeneity was found
(F=3.194, df--69, p<0.05) in ZBI
scores between these three groups.
However, the post hoc Scheffe test
showed no significant differences
between any two of these groups.
The study found that 36% of
caregivers received support from
either maids or private nurses. This
formal support was limited to only
paid service by a nurse or a maid who
was privately employed to assist in the
activities of daily living. Interestingly,
ZBI scores were similar for those
purchasing and not purchasing these
services (F=1. 109, d.F68,p>0.05) and
between those who have and who do
not have formal support.
Discussion
The study found that ethnicity was a
predisposing factor for burden among
the dementia caregivers. Chinese and
Indian caregivers were found to be
more highly burdened than Malays.
Although this current study may not
be able to provide an explanation on
how ethnicity exerts its impact on
burden among caregivers, one
possible answer that explained the
lower burden perceived by the Malay
caregivers perhaps can be found in a
local study by Salleh’S who
investigated the burden of care of
schizophrenia in Malay families. The
author found that despite the fact that
Malay caregivers were burdened,
caregivers do not complain about the
situation they were in and were
generally able to tolerate the negative
symptoms of their schizophrenic
family members. One could speculate
the possibility that Malay caregivers
might interpret dementia as a normal
part of ageing, based on what was
found in Patel and Prince’s study 16
among the Goans in India. Filial
obligation coupled by the societal
norm of assigning caring
responsibility of the impaired elders
to their families, is still very much
intact across all cultures in the
Malaysian population&dquo;. Cultural
Table 3. Association between socio-demographic factors, social support and
burden
*Significant at 0.05; US$1 =
RM3.84
differences may, however, influence
how filial obligation and burden are
related in the care-giving process. For
example, one study in Taiwan 18 found
evidence that filial obligation was a
strong predictor of burden among
caregivers. The author suggested that
filial obligation, may be the primary
motive for care-giving, as a result of
the much-embedded Chinese
traditional cultural value of filial piety
in the Chinese society.
In our convenience sample the
Chinese comprised the largest group
of dementia patients. This may
represent a selection bias, given that
most patients were recruited in urban
areas with a higher concentration of
Chinese families. However,
demographic ageing is more advanced
in the Chinese than in the Malay or
Indian sector of the Malaysian
population; in the 1991 Census, 7.6%
of the elderly were Chinese, notably
higher than the proportions of senior
citizen among the Malays (5.4%) and
Indians (5.4%)19. With the lower
mortality and longer life expectancy
among the Chinese, it is postulated
that the likelihood of this group
sufferingfrom a dementia syndrome
may be slightly higher.
Also, there is a possibility that
Malays, Chinese and Indians may
differ in their responses to measures
use to detect burden although all of
them might feel similarly burdened.
These differences might result from
the use of scales whose items are only
relevant to certain ethnic groups or
from caregivers’ discomfort in
revealing personal feelings to
interviewers of a different race.
Furthermore, measurements
developed in developed western
countries, may be subject to cultural
bias if applied locally. Indeed,
Jackson20 found biased responses to
standard survey items due to different
cultural values of White and minority
elderly adults.
Various scholars have also
attempted to explain the influence of
caregivers’ ethnicity and racial
differences with regard to the feelings
of burden among dementia caregivers.
Haley2’ suggested that cultural
differences on factors particularly
expectations about care-giving and
previous experiences with adversity,
may affect the burden perceived by
caregivers of various ethnicity. Other
possible answers to ethnic differences
in perceived burden identified by Lim
and colleagues22 was the meaning of
care-giving that caregivers ascribe to
their situation. He further explained
that cultural value help to frame the
27
meaning of care-giving, while
hitherto, the meaning of care-giving
mediates the caregiver’s perception of
burden and the cultural norms and
standards for expression of burden.
The authors gave an example of the
Mexican Americans who viewed care-
giving as a dignified way of accepting
fate and ensuring a place in heaven,
of help to facilitate individual and
spiritual development. Care-giving is
viewed positively as self-sacrificing,
devoted and protective, thus caring for
an elder was regarded as a source of
pride and status. A similar study that
explore ethnicity differences between
the Black and White caregivers was
by Farran and coworkers23 who
postulated that Black caregivers have
culturally learned to adapt or to
survive difficult situations by making
positive appraisals or due to the fact
that they do not have the luxury of
being depressed or distressed by their
external environment than the Whites
do.
The findings also show that
informal support in particular,
assistance from family members were
significantly associated with the lower
burden perceived by the caregivers.
Similarly, Coen and colleagueS14 noted
that burden is predicted by decreased
levels of informal social support and
increased levels of patient behavioural
disturbances. Likewise, Escober and
Randolphzs also suggested that strong
social bonds and loyalty to the family
may support and buffer caregivers.
Strong social bonds may influence the
perception of care-giving burden
particularly if care-giving responsibili-
ties are distributed among family
members. Further, Meshefedjian and
colleagues26 pointed out that ethno-
cultural factors brought about the
differences observed in the structure
of informal caregiver networks, thus
affecting the availability of informal
support for caregiver and opportuni-
ties for the sharing of care-giving
duties.
Informal support particularly
from family members, still play an
important role in mediating and
buffering caregivers’ burden. Like any
other Asian culture, the value for the
family above individual is strongly
emphasized, thus individuals’
emotional well-being and sense of
28
identity are closely tied to the family.
Needless to say, the family will
continue to be the single most
important source of support for the
elderly and filial piety continues to
play an important role in the care of
the elderly. Moreover, unlike many
other countries such as United States,
Malaysia has relatively few nursing
home institutions, while the existing
ones are less affordable to many.
However, the breaking up of the
traditional structure of extended
families, smaller family sizes, greater
participation of women in the labour
force and growing geographical
mobility and travelling distance will
come to limit the ability of Malaysian
society to rely entirely upon informal
care for older persons. Nevertheless,
it is essential that government policy
operates in such a way that it
encourages informal care if we want
to continue emphasising informal care
as the means of meeting growing care
needs in the society. Policy makers
should emphasise services designed to
support caregivers in providing care,
bolstering their self-efficacy and
coping repertoire, and enhancing their
support network.
Steps should be taken to enhance
the quality of life of caregivers, care
recipients and other family members.
This could include support groups for
caregivers that can be run by
professionals such as social workers
and volunteers; education sessions or
sharing sessions with physicians on
typical symptoms, causes and the
expected courses of dementia to
family members; and the
establishment of family therapy clinics
to which families can be referred for
counselling and support for family
members of the demented patients.
Such measures are useful when the
dementia illness of a family member
triggers unresolved issues among
family members, interferes with
patient’s treatment as well as causes
distress to family members; provision
of health care professionals to make
regular home visits especially for
patients who are immobile;
establishment of day nursing/care
especially to cater for the needs of
dementia patients to relieve the
primary caregivers and the provision
of respite care to relieve the chief
caregiver by taking over their tasks of
caring on a temporary basis.
Rather surprisingly, the study
shows that formal support such as
assistance from maids and private
nurses did not alleviate the burden of
caregivers. One may postulate that
although maids may alleviate
caregivers in terms of assisting
caregivers to provide physical
assistance to patients in performing
basic activities of daily living, this
alleviation does not directly translate
to other aspects that are related to
caregivers’ burden such psychological
or emotional, social and financial
problems. Similar findings were also
found by Li and colleagueS21 on the
buffering effects of two groups: care-
giving wives and daughters who show
depressive symptoms. Interestingly,
the authors found evidence that care-
giving support, in this case, was
measured as the presence of formal
assistance or another person to help
with care-giving tasks and did not have
any buffering effect on the caregivers.
Therefore, emotional support perhaps
has a greater effect on buffering stress
which is unlikely to be provided by
maids compared to family members
as shown in this study. Emotional
characteristics of the care-giving
situation and lack of resources were
the main factors that have a greater
effect on the caregiver’s well being,
not the extent of the duties imposed
on him or her3.
Conclusion
This research has highlighted the
importance of ethnicity and cultural
differences that exist in our society that
should be taken into consideration
before the implementation of any
intervention. This study has revealed
interesting differences in care-giving
among the various ethnic groups that
warrant further research. Future
studies on dementia care-giving issues
should explore the different cultural
perceptions on dementia and care
arrangement for the elderly population
among these ethnic groups.
Qualitative studies, in this case, may
be able to offer additional insights into
how specific strategies for coping with
the demands of care-giving vary
across ethnic groups and cultures.
Acknowledgements
The author wishes to acknowledge the
University of Malaya for supporting
this research study through the
provision of funds via Vote F. This
study is also a part of the 10/66
Dementia Research Group initiative.
To all caregivers of this research study,
the authors convey their sincere thanks
and respect to all for their contribution
and sharing of experiences.
References
1. Fredman L. Caregiver Issues. In:
Adelman AM, Daly MP. Twenty
Common Problems in Geriatrics.
Boston: McGraw Hill Publishing
2001 : 54-67.
2. Dunkin JJ, Anderson-Hanley C.
Dementia caregiver burden: a review
of the literature and guidelines for
assessment and intervention.
Neurology 1998; 51(1): 53-60.
3. Zarit SH, Reever KE, Bach-Peterson
J. Relatives of the impaired elderly:
correlates of feelings of burden.
Gerontologist 1980; 20(6): 649-55.
4. Donaldson O, Tarrier N, Burns A.
The impact of the symptoms of
dementia on caregivers. Br J
Psychiatry 1997; 170: 62-8.
5. Yee JL, Schulz R. Gender differences
in psychiatric morbidity: a review and
analysis. Gerontologist 2000; 40(2):
147-64.
6. Janevic MR, Connell CM. Racial,
ethnic and cultural differences in the
Dementia caregiving experience:
recent findings. Gerontologist 2001;
41 (3):334-47.
7. Gywether LP, Strulowitz SY. Care-
giver stress. Curr Opin Psychiatry
1998 July; 11(4): 431-4.
8. Haley WE, Levine EG, Brown SL,
Bartolucci AA. Stress, appraisal,
coping, and social support as
predictors of adaptational outcome
among dementia caregivers. Psychol
Aging 1987; 2: 323-30.
9. Atienza AA, Collins R, King AC. The
mediating effects of situational
control on social support and mood
following a stressor: a prospective
study of dementia caregivers in their
natural environments. J Gerontol
2001; 56B(3): S129-39.
10. Zarit SH, Zarit JM. The Memory and
Behaviour Problems Checklist and
the Burden Interview. University
Park, PA: Penn State University
Press; 1990.
11. Bristil RW. Back-translation for cross
cultural research. J Cross Cult
Psychol 1970; 3: 185-216.
12. Chui HFK. Department of Psychiatry,
Chinese University of Hong Kong,
personal communication, 2001.
13. Horowitz, A. Sons and daughters as
caregivers to older patients:
differences in role performance and
consequences. Gerontologist 1985;
25: 612-7.
14. Ory MG, Hoffman RR, Yee JL,
Tennstedt S, Schulz R. Prevalence
and impact of caregiving: a detailed
comparison between dementia and
non-dementia caregivers.
Gerontologist 1999; 39(2):177-85.
15. Salleh MR. The burden of care of
schizophrenia in Malay families.
Acta Psychiatr Scand 1994 Mar;
89(3):180-5.
16. Patel V, Prince M. Ageing and mental
health in a developing country: who
cares? Qualitative studies from Goa,
India. Psychol Med 2001; 31 (1): 29-
38.
17. Arokiasamy JT. Malaysia’s aging
issues. Med J Malaysia 1997; 52
(3):197-201.
18. Chou KR, LaMonagne LL, Hepworth
JT. Burden experienced by caregivers
of relatives with dementia in Taiwan.
Nurs Res 1999; 48(4): 206-14.
19. Ong FS. Ageing in Malaysia: a
review of national policies. Kuala
Lumpur, University of Malaya,
Faculty of Business and Accountancy,
1999 (unpublished paper).
20. Jackson JS. Methodological issues in
survey research on older minority
adults. In: Lawton MP, Herzog AR,
editors. Special Research Methods
for Gerontology. New York:
Baywood. 1989.
21. Haley, WE. The family caregiver’s
role in Alzheimer’s disease.
Neurology 1997; 48(5) Supp 6:&dagger;25S-
9S.
22. Lim YM, Luna I, Cromwell SL,
Phillips LR, Russell CK, Torress de
Ardon E. Toward a cross-cultural
understanding of family caregiving
burden. Western J Nurs Res 1996;
18(3): 252.
23. Farran CJ, Miller BH, Kaufman JE,
Davis L. Race, finding meaning and
caregiver distress. J Aging Health
1997; 9(3): 316-33.
24. Coen RF, Swanwick GR J, O’Boyle
CA, Coakley D. Behaviour
disturbance and other predictors of
carer burden in Alzheimer’s disease.
Int J Geriatr Psychiatry 1997; 12(3):
331-6.
25. Escober J, Randolph E. The Hispanic
and social networks. In: Becerra R,
Karno M, Escobar J, editors. Mental
health and Hispanic Americans:
Clinical Perspectives. New York:
Grune Stratton. 1982: 41-57.
26. Meshefedjian G, McCusker J,
Bellavance F, Baumgarten M. Factors
associated with symptoms of
depression among informal
caregivers of demented elders in the
community. Gerontologist 1998;
38(2): 247-53.
27. Li LW, Seltzer MM, Greenberg JS.
Change in depressive symptoms
among daughter caregivers: An 18-
month longitudinal study. Psycho
Aging 1999 June; 14(2):206-19.
29